Free 41707.pdf - Indiana

County

PERSONAL SERVICES SCHEDULE Cooperative Agreement Appendix 1-b
State Form 41707 (R2 / 3-96) / FM 0900

Budget year

INSTRUCTIONS:

Please indicate if employee is full-time or part-time for Title IV-D. JOB TITLE AVERAGE HRS/WEEK FULL-TIME/ PART-TIME CSD USE ONLY ANNUAL SALARY A A A A A A A A A A A A TOTAL PERSONAL SERVICES (Carry to Line 101 Form 901) EMPLOYEE BENEFITS COUNTY CONTRIBUTIONS BENEFIT CODE (circle) B B B B B B B B B B B B C C C C C C C C C C C C D D D D D D D D D D D D E E E E E E E E E E E E

TOTAL

A. Social Security contributions at ____________________ % (Carry to Line 102A - Form 901) B. Retirement contributions at _______________________ % (Carry to Line 102B - Form 901) C. Group Insurance (explain below) . . . . . . . . . . . . . . (Carry to Line 102C - Form 901) D. Unemployment Insurance ____________ % (Maximum $ ___________ / empl.) E. Other (specify) . . . . . . . . . . . . . . . . (Carry to Line 102E - Form 901)
TOTAL EMPLOYEE BENEFITS (Carry to Line 102 - Form 901)

(Carry to Line 102D Form 901)

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